Your Medical Record

Recently I reorganized my medical records. I started getting copies of them when I was in college. It was at this time that I was diagnosed with a medical condition that required surgery for a cure. That is pretty shocking. I decided that after several years of doctors’ testing and untimely diagnosis I must see what is being written about me.

By getting a copy my medical record from that doctor, I was more informed. Thereafter I continued to get copies of my medical records including blood tests and all other tests as well as surgery notes. I also started doing it for my parents and my whole family. Your medical record is the cornerstone and foundation of your medical care. It is the most important communication aside from direct patient to doctor conversation.

It sure would be nice to write it all down. The doctor writes, types, or dictates as much as possible. This important conversation including what is found on the physical exam, the diagnosis/ diagnoses, an assessment of tests done, and a plan for treatment is documented by writing, typing, or dictating. That is a lot of information to document. Accuracy is of utmost importance. The medical record is the communication tool used by all your health care providers.

It is only right that you should be able to see your medical record about you. Checking for accuracy and information in your records is important. It is empowering. It makes you want to take the best care of yourself, and be able to talk more openly to your doctor about it. I have found this to be true amongst patients that keep their medical records. I have seen medical errors avoided. I have learned more from patients about their own medical conditions because they read about them.

The best way to obtain your medical record is to obtain a record release form. Your doctors’ office should have this document. Ask for it. After completion return it to the person in charge of medical records at the office, hospital, or other medical care facility via mail, fax, or in person. A copy of the medical record is sent directly from the office, or it may be sent from a company that sends out medical records. How this is done is beyond me especially when the company is in another state. Getting the record directly from the health care provider seems easiest for the patient.

Sadly, you may have to pay for your records. It is best to get copies from your doctor at the time of your visit. Most doctors have it finished by the time you leave. When tests are ordered, the results can be faxed or mailed after your doctor talks to you about the results. This may avoid costs, and help ensure timely follow-up. I have found some doctors’ offices automatically give you this information. How nice!

Medical record retrieval can be challenging, but rewarding. Keeping current with your health is your job. You are your most important asset.

Information on obtaining a medical record release at http://www.mypatienthandbook.com/ under "Patient Tools”.

--by J.L. Richardson, MD, family medicine, is author of the award winning Patient Handbook to Medical Care: Your Personal Health Guide".

http://mypatienthandbook.com